Healthcare Provider Details

I. General information

NPI: 1295450666
Provider Name (Legal Business Name): KASEY R KOSTYSHAK MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8408 WATT AVE
ANTELOPE CA
95843-9116
US

IV. Provider business mailing address

8201 SILVERSIDE DR
ANTELOPE CA
95843-4805
US

V. Phone/Fax

Practice location:
  • Phone: 916-747-0817
  • Fax:
Mailing address:
  • Phone: 916-747-0817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number23306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: